The United States Preventive Services Task Force (USPSTF) has issued a statement, published in JAMA that reaffirms its 2009 recommendation for screening pregnant women for hepatitis B virus (HBV) infection at the first prenatal visit.
Despite existing guidelines for universal HBV vaccination in infants, the rate of maternal HBV have increased by 5.5% every year since 1998. From 1998 to 2011, data from a nationally representative sample demonstrated a prevalence of maternal HBV of 85.5 per 100,000 deliveries. Because infection with HBV during infancy or childhood increases the likelihood of chronic infection, which then increases long-term morbidity and mortality, the USPSTF issued a grade A recommendation for HBV screening during pregnancy in 2009.
The USPSTF has presently undertaken deliberation through the reaffirmation process to evaluate high-level evidence that may justify a change in the grade of this recommendation. Previously reviewed evidence on hepatitis B surface antigen (HBsAg) serologic testing during pregnancy demonstrated both sensitivity and specificity >98%.
In evaluation of benefits and harms of interventions for HBV screening, the USPSTF reported the following:
- Universal prenatal HBV screening demonstrated a significant reduction in prenatal transmission of HBV, and therefore in chronic HBV.
- There was adequate evidence for substantial reduction in the risk for HBV in infants through the use of universal HBV vaccination at birth and postexposure prophylaxis with hepatitis B immunoglobulin for infants of mothers with HBV.
- Limited evidence was found regarding harms of HBV screening in pregnant women.
Therefore, the USPSTF recommends that all pregnant women should be screened for hepatitis B via serologic testing for HBsAg at the first prenatal visit for each pregnancy, regardless of previous negative HBsAg, or previous HBV vaccination.
In addition, women with risk factors such as sexually transmitted infections or injection drug use, or who have an unknown HBsAg status should be screened for HBV at the time of delivery.
To decrease vertical transmission of HBV, the USPSTF also recommends treatment for mothers with HBV, vaccination of infants within 24 hours of delivery and completion of the vaccine series by age 18 months. In the case of mothers with HBV, recommendations include maternal HBV DNA viral load testing, and specialist care in conjunction with infant HBV vaccination and hepatitis B immunoglobulin administration within 12 hours of birth, completion of the vaccine series by 8 months, and HBV serologic testing for immunity at age 9 to 12 months. For infants of mothers with unknown HBsAg status, recommendations were made for HBV vaccination within 12 hours of birth, followed by hepatitis B immunoglobulin prophylaxis.
Further, emerging evidence supports the administration of tenofovir to women with acute HBV infection in combination with infant HBV vaccination and hepatitis B immunoglobulin administration as a mechanism for the significant reduction in the risk of developing HBsAg positivity.
The USPSTF identified 2 observational studies of fair quality that reported perinatal HBV transmission rates. The first study demonstrated that between 1994 and 2008 the number of infants born to women with HBV in the United States increased from 19,208 to 25,600. However, during the same period, perinatal transmission of HBV in infants who received serologic testing decreased from 1.9% to 0.8% (P =.001). The second study of 4446 infants born to women with HBV between 1997 and 2010 demonstrated that 97% of these infants received the vaccine for HBV, and hepatitis B immunoglobulin within 12 hours of birth, and the rate of perinatal transmission was 0.75%.
Despite the standard of care being universal screening for HBV in pregnant women, roughly half of the states in America have do not have laws that mandate prenatal screening for HBV. The rate of maternal HBV screening ranges from 84% to 85%, but this occurs within the first trimester of pregnancy in 60% of commercially insured women, and 39% of those enrolled in Medicaid. In addition, 71% of infants receive vaccination for HBV within 3 days of birth.
Therefore the USPSTF “reaffirms its previous conclusion that there is convincing evidence that screening for HBV infection in pregnant women provides substantial benefit” and the highlighted evidence suggests that there are still significant gaps to close in order to attain widespread provision of such benefits.
United States Preventative Task Force. Screening for hepatitis B virus infection in pregnant women US preventive services task force reaffirmation recommendation statement. JAMA. 2019;322(4):349-354.